Justification for nonmaterial change ca-278

Justification for Non-material/Non-substantive Change

ICR 1240-0006

Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act (CA-278)

The Office of Workers' Compensation Programs (OWCP) administers the Federal Employees' Compensation Act (FECA), 5 U.S.C. 8147 and the War Hazards Compensation Act (WHCA), 42 U.S.C. 1701. The statutes provide for the reimbursement of payment by insurance carriers and self-insured to workers injured due to a war-risk hazard. The information collected from the CA-278 allows OWCP to consider requests filed by insurance carriers and self-insured that have paid benefits to workers injured due to a war-risk hazard to be reimbursed for such benefits out of the Employees’ Compensation Fund. Before compensation may be paid, the case file must contain medical evidence showing that the claimant's disability is causally related to the claimant's federal employment.

The program request two minor changes to the form and instructions.

The first change on the first page involves reformatting of the following statement:

Currently Reads:

BENEFITS PAID AND AMOUNT CLAIMED AS CLAIMS EXPENSE

Periodic payments $____________ Claims Expenses $____________

Medical payments $ ___________ Period covered from ____________

Burial Payments $ ___________ to ____________

(inclusive dates)

Other $ ___________ Specify: ____________

Total of Above $ __________

Revised:

BENEFITS PAID AND AMOUNT CLAIMED AS CLAIMS EXPENSE

Periodic payments $____________ Period covered from ____________

Medical Payments $____________ to ___________

(inclusive dates)

Burial Payments $ ___________

Other $ ___________ Specify: ____________

Claims Expenses $___________

Total of Above $ ___________

The second change involves a change of address.

Item 1 in the instructions advises the respondent to forward the completed form to the Office of Workers' Compensation Programs, Division of Federal Employees', Longshore and Harbor Workers' Compensation, Federal Employees' Compensation Act, (OWCP/DFELHWC-FECA), PO Box 8311, London, KY 4072-8311. Rather than mailing this document to our contract facility in London, KY, the Program is requesting this address be sent directly to a Program office with the following address:

Currently reads:

Mail one copy of this form with the attached supporting documents described below to the Office of Workers' Compensation Programs, Division of Federal Employees', Longshore and Harbor Workers' Compensation, Federal Employees' Compensation Act, (OWCP/DFELHWC-FECA), PO Box 8311, London, KY 4072-8311

Revised:

Mail one copy of this form with the attached supporting documents described below to

US Department of Labor - OWCP/DFELHWC

Attn: War Hazards

400 West Bay Street

Room 826

Jacksonville, FL 32202